Patient Registration Form

PATIENT NAME

Last Name

First Name:

Middle Initial:

ADDRESS

Local Mailing Address:

City:

State:

Zip:

Permanent Mailing Address:

City:

State:

Zip:

Home Phone #:

Cell Phone:

Email:

Race:

Ethnicity:

Language:

Social Security Number:

Sex:

Male Female

How did you hear about us?

EMERGENCY CONTACT

Name:

Phone:

Relationship:

Company:

Occupation:

Work Phone:

Responsible Party

Patient:

Other:

If Other, please complete this section

Name:

Address:

City:

State:

Zip:

DOB:

SSN:

Home #:

Cell #:

Work #:

INSURANCE INFORMATION

Do you have insurance?

Yes No

If "No" please note that payment is expected as services are rendered.
If "Yes" Please Upload a picture of your card and complete the following Section

Upload Card Photo:

Add file

Please upload a file

Name of Primary Insurance Company:

Member ID#:

Group #:

Name of insured as it appears on card:

Insured's Date of Birth:

Name of Secondary Insurance Company:

Member ID#:

Group #:

Name of insured as it appears on card:

Insured's Date of Birth:

If insured person is other than the patient please complete the following:

Name:

Address:

City:

State:

Zip:

Date of Birth:

SSN:

Home #:

Cell #:

Work #:

CONSENT FOR TREATMENT

I consent to the care and treatment by Dr. Cabiran, Jane Pressler FNP-DC, Christopher Trotter, PA, and or Lindsey D. Koach, NP. The treatment may include but is not restricted to medications, anesthesia, surgical and invasive procedures, lab, x-ray, or other studies that may be helpful in the performance of the patients care.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Today's Date:

ASSIGNMENT OF BENEFITS AND GUARANTEE OF ACCOUNT

I acknowledge full financial responsibility for any services rendered and I understand that the payment of charges incurred in this office is due at the time of service. I also understand that I am financially responsible for all co-payments and any charges that are not paid my insurances. I authorize payment directory to Dr. Cabiran, Jane Pressler FNP-DC, Christopher Trotter, PA, and or Lindsey D. Koach, NP, for all medical or surgical benefits otherwise payable to me under the terms of my insurance. In the event an account is turned over to a collection agency, I agree to pay all cost of collection including reasonable attorney’s fees and hereby waiver all rights of exemption under the constitution of the State of North Carolina/Georgia. I certify the information I have reported with regard to my insurance coverage is correct.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Today's Date:

Exposure to Disease

I understand that if my provider(s), or any person employed by or under the direction and control of my provider(s), is directly exposed to my body fluids in any manner which may, according to the current guidelines of the Centers for Diseases Control, transmit the Human Immunodeficiency Virus (HIV) or Hepatitis B or C viruses, that I am deemed by law to have consented to testing for infection with HIV or Hepatitis B or C viruses. I futher understand that by law I am deemed to have consented to the release of these test results to those who were exposed to my body fluids.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Today's Date:

MEDICAL HISTORY

Last Name:

First Name:

Middle Initial

Date of Birth:

Reason for today's visit:

If cancer, please specify type:

If other, please specify:

If Other, please specify:

Do you wear sunscreen?

Yes No

If yes, please specify the strength of your sunscreen:

Do you have personal history of melanoma?

Yes No

Does your family have history of melanoma?

Yes No

Please list ALL prescription medication that you are currently taking:

Please include strength and how often you take the medication

Add another medication

Allergies

Add new row

Do you smoke?

Yes No

Have you ever smoked in the past?

Yes No

Do you drink alcohol?

Yes No

If you do drink alcohol, how much?

Less than 1 drink per day 1-2 per day More than 3 per day

If over 65 years old, have you had more than (5 drinks for men/4 drinks for women) in one day?

Yes No

If yes, How many times in the past year?

Did you receive a flu vaccine during the current flu season? (October to April)

Yes No

If 65 or older: Have you ever had a pneumonia vaccine?

Yes No

Do you have a family history of the following?

None

Diabetes:

Mother

Father

Elevated Cholesterol:

Mother

Father

High Blood Pressure:

Mother

Father

Please answer to the following questions to comply with the Medicare EHR incentive Program.

Name of Pharmacy:

City:

State:

Zip:

Name of Primary Care Physician:

City:

State:

Zip:

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Date:

Your information will be encrypted.